CHRONIC DIARRHOEA

Chronic Diarrhoea

Diarrhoea lasting for more than 4 weeks Mainly non infections causes

causes1. Secretory causes2. Osmotic causes3. Steatorrheal causes4. Inflamatory causes5. Dysmotility causes6. Factitial causes

Secretory causes

Derangements in fluid and electrolyte transport across entero colonic mucosa

Watery,large volume fecal output,painless and persits with fasting

1)medications—ethanol,laxatives 2)bowel resection,mucosal

d/s,enterocolic resection—idiopathic secretory

diarrhoea

3)hormones- serotonin,prostaglandins,kinins

4)congenital defects in Fe absorption

Osmotic causes Osmotically active solutes 1)osmotic laxatives—Mg2+,(po4)3-,

(so4)2- 2)carbohydrate malabsorption—lactase

deficiency

Steatorrheal causes

1) intraluminal maldigestion—c/c pancreatitis,

fibrosis,pancreatic duct obstruction 2)mucosal malabsorption—celiac

d/s,tropical spure,whipples d/s 3)post mucosal lymphatic obstruction—

congenital intestinal lymphangiectasia,acquired lymphatic obstruction(trauma,tumour)

Inflamatory causes

Pain,fever,bleeding,other manifestations ofinflamation

eg:IBD,immunodeficiencies,eosinophilic gastrits,c/cGVH

Dysmotility causes

Hyper motility Diabetic diarrhoea—peripheral

andgeneralised autonomic neuropathy

Factitial causes 15% of unexplained diarrhoea Eg:munchausen syndrome,eating

disorders(psychiatric illness)

Approach to the patient Proper history and physical examination

very important HISTORY—

onset,duration,pattern,aggrevating and relieving factors etc

wt.loss,pain,exposures(travel,medications etc)

.FAMILY HISTORY—ibd,sprue

PHYSICAL EXAMINATION -- anemia,edema,clubbing(features of

malabsorption,IBD) --muco cutaneous manifestations of

systemic d/s(dermatitis herpetiformis,erythema nodosum,oral ulcers etc)

--abdominal mass or tenderness --abnormalities of rectal mucosa,rectal

defects

Diagnostic evaluation directed by a careful history and physical examination

If not revealing triage tests required to direct the choice of complex investigations

Traetment Curative,suppressive,empirical 1)curative—antibiotic for whipples

d/s,discontinuation of drug 2)suppressive—elimination of dietry

lactose,PPI for gastrinoma,pancreatic enzyme replacement

3)emperical—mild opiates(loperamide),clonidine,fluid and electrolyte replition

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